Main Causes of Maternal Death
Hemorrhage Definition and prevention. '''Hemorrhage is a significant bleed, and in post partum mothers hemorrhage occurs due to a variety of different reasons, mostly due to a problem involving the placenta. In recent years, there has been an increase in women presenting with placenta previa, accreta and long inductions, which increase the risk for severe hemorrhage (Main, 2017, Results section, p 298.e5, para. 6). Accreta, a condition once considered extremely rare, is now occurring in around 1/500 births due to Americas increased C-section rate. Accreta occurs when the placenta embeds itself causing hemorrhage after delivery. This condition is believed to be caused by scarring from prior C-sections. The hemorrhaging from accreta kills one in fourteen women presenting with this condition (Belluz, 2017, para. 2-3). If hemorrhage is treated and the cause (accreta) is not taken care of, a deadly clotting disorder develops due to tissue left in the uterus after delivery (Belluz, 2017, para. 5). Regardless of reasoning for hemorrhage, standards must be put into place to decrease death from something so common. This is not only a problem in the United States, between 1997 and 2005 the transfusion rate in mothers admitted to labor and delivery nearly doubled with similar statistics found in Canada, Australia and Europe (Shields et al., 2015, p. 272). California’s success in reducing maternal death served as a template to the National Partnership for Maternal Safety Consensus bundle for Obstetric Hemorrhage. The content of the guide includes readiness, recognition and prevention, response, as well as reporting and system improvement with individual elements per section (Main et al., 2017, Introduction section, p. 298.e1, para. 1). '''Research and review. One of the problems with research and review is the lack of diagnosis and coding for obstetric hemorrhage. Researchers provided information that prior to the hemorrhage guide, woman were receiving transfusions without the diagnosis of obstetric hemorrhage in their history or reports section (Main et al., 2017, Materials and Method section, p 298.e3, para. 7). This makes it difficult to report on maternal hemorrhage due to inconsistent reporting. In addition to coding problems, blood loss was not being measured. This lead to new policies to ensure accurate measurements such as weighing all materials in contact with blood as well as fluid collection systems would be obtained. The only discrepancy is amniotic fluid measured in with blood that proved to not effect the outcome as methods of improvement increased (Shields et al., 2015, Materials and methods section, p. 273, para. 5). Multiple studies over several different types of hospitals were done with results showing a large amount of non compliance, primarily due to physician reluctance (Shields et al., 2015, Results section, p. 276, para. 1-3). Treatment and results. 'The hemorrhage policy described in the ''American Journal of Obstetrics and Gynecology was composed of stages including stage one that was primarily handled by nursing staff and uterotonic agents, stage two (as pictured in Figure 2) involving a doctor and the introduction of a hemorrhage cart, and stage three (>1500 ml of blood loss) with addition of physician and surgical support. Stage three initiated blood products for transfusion (Shields et al., 2015, Materials and methods section, p. 274, para. 5-7). Once compliance increased and standards improved, patients that fell under the hemorrhage protocol moved to 60% in stage three. Although there was an increase in stage progression, there was a decrease in medication and transfusion rate due to alternative methods and early intervention. Said interventions also decreased the rate of hysterectomy due to hemorrhage by 14.8% (Shields et al., 2015, Results section, p. 276, para. 1-3). It was unexpectedly noted that hospitals taking part in improvement for the second time had twice as much success compared to those establishing protocols for the first time (Main et al., 2017, Comments section, p. 298.e5, para. 3). '''Figure 2: Sample of Hemorrhage Protocol Shields, L. E., Wiesner, S., Fulton, J., & Pelletreau, B. (2015). Comprehensive maternal hemorrhage protocols reduce the use blood products and improve patient safety. doi:10.1016/j.ajog.2014.07.012 Each hospital showed a significant improvement due to something as simple as a developed policy of treatments and considerations that should have already been happening. Woman who gave birth in hospitals participating in the hemorrhage control program experienced a 20.8% reduction in maternal mortality in comparison to non participating hospitals 1.2% non-significant reduction. Hospitals with prior hemorrhage policies had a 28.6% reduction whereas those with no prior policy experienced a 15.4% reduction section (Main et al., 2017, Results section, p 298.e4, para. 2). The primary goals of policy were to enhance communication with the healthcare team, continuing education regarding the protocol and blood loss assessment, standardized treatment, early physician assessment, and early intervention (Shields et al., 2015, Comment section, p. 279, para. 4). The policies put in place proved to be exponentially effective in decreasing death caused by hemorrhage, but also decreased maternal deaths as a whole. Preeclampsia Definition and prevention. '''Twelve percent of maternal deaths in the United States are directly linked to preeclampsia, “a multisystem inflammatory syndrome with an unclear etiology and natural history. It is one of the leading causes of maternal and perinatal morbidity and the second-leading cause of maternal mortality worldwide” (Lefevre, 2014, Discussion section, p. 822, para. 1 & 2). '''Preeclampsia presents with a blood pressure >140/90 and proteinuria. According to Annals of Internal Medicine “preeclampsia also accounts for 15% of preterm births in the United States” as well as 2%-8% of complications worldwide (Lefevre, 2014, Rationale section, p. 819, para. 1). Although this complication is extremely prevalent, no calculations have shown to be effective at predicting woman at risk for preeclampsia (Lefevre, 2014, Rationale section, p. 820, para. 1). Healthcare may be a large contributing factor to women developing preeclampsia due to large amounts of IV fluids overloading the kidneys, pain medications, as well as medications to treat uterine atony (Sibai, 2012, New-onset postpartum hypertension-preeclampsia section, p. 470-471, para. 1-2). Some of these interventions are medically necessary however, a majority of the time the treatments are preventative and may do more harm than good. The United States Preventative Services Task Force (USPSTF) pursued a method of prevention for preeclampsia by use of low dose aspirin. Aspirin at doses of 60-150mg reveled a 24% reduced risk in women in a clinical trial. The preventative measure also showed that there was no increase in other complications such as placental abruption or hemorrhage for the mother nor the fetus (Lefevre, 2014, Rationale section, p. 820, para. 3-5). '''Aspirin study and discharge. '''Continued research is still needed on the response to aspirin use as well as improvement on healthcare providers’ ability to identify women at risk for preeclampsia. Efforts should direct healthcare providers to continuously monitor, reporting and prompt evaluation of symptoms for proper treatment. Prevention efforts should also be made by obtaining a history and physical exam for all women with close evaluation to the populations more susceptible to preeclampsia (Sibai, 2012, Evaluation and management of postpartum hypertension section, p. 474, para. 14). Aspirin is used as a preventative medication in a vast amount of the elderly population as it decreases inflammation, angiogenesis and antiplatelet properties that often cause heart disease and heart attacks. The aspirin works in the same manor in pregnant women to treat the inflammation, poor perfusion and stress from the placenta (Lefevre, 2014, Discussion section, p. 822, para. 26). Complications from preventative aspirin use were shown to be insignificant. Analysis revealed that during the study, use of aspirin versus placebo played no difference in cesarean section rate between groups. Researchers also collected that blood loss was less or did not change in mothers using low dose aspirin (Lefevre, 2014, Discussion section, p. 822, para. 1-2, 21). Arguably the most important factor in prevention and treatment is discharge education. In post partum mothers blood pressure normally decreases in the first 48 hours but increases again within 3-6 days (Sibai, 2012, Persistaence/exacerbation of hypertension-protinuria section, p. 471, para. 1). A mother is normally discharged by day three when preeclampsia is beginning to return. The lack of education and treatment can lead to severe complications and death in mothers.